MEDICARE: KRIS A. PROBASCO LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	000567	MO

General Provider Information

NPI Number	:	1336211440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRIS A. PROBASCO LCSW

Provider Business Mailing Address
First Line	:	1135 W KANSAS ST
Second Line	:	SUITE B
City	:	LIBERTY
State	:	MO
Zip	:	64068-2281
Country	:	US
Telephone Number	:	816-781-8550
Fax Number	:	816-792-3219

Provider Business Practice Location Address
First Line	:	1135 W KANSAS ST
Second Line	:	SUITE B
City	:	LIBERTY
State	:	MO
Zip	:	64068-2281
Country	:	US
Telephone Number	:	816-781-8550
Fax Number	:	816-792-3219

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	07/08/2007

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